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 Table of Contents  
REVIEW ARTICLE
Year : 2019  |  Volume : 3  |  Issue : 1  |  Page : 24-28

Prevention of pressure injury in the intensive care unit


Intensive Care Department, Ministry of National Guard- Health Affairs; King Abdullah International Medical Research Center; College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

Date of Web Publication30-May-2019

Correspondence Address:
Hasan M Al-Dorzi
King Abdulaziz Medical City, ICU2, Mail Code 1425, PO Box. 22490, Riyadh 11426
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2543-1854.259474

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  Abstract 


Pressure injury (PI) is common in critically ill patients and is largely preventable. Prevention of PI in the intensive care unit (ICU) depends on routine risk assessment and implementation of preventive measures, such as adequate nutritional support, proper positioning and repositioning, mobilization, proper skin care, use of appropriate pressure-redistributing surfaces, and application of skin protective dressings. The available evidence suggests that a multifaceted approach is usually required. In addition, there is a need for high-quality studies to guide PI prevention in ICU patients.

Keywords: Intensive care, pressure ulcer, repositioning, support surface


How to cite this article:
Al-Dorzi HM. Prevention of pressure injury in the intensive care unit. Saudi Crit Care J 2019;3:24-8

How to cite this URL:
Al-Dorzi HM. Prevention of pressure injury in the intensive care unit. Saudi Crit Care J [serial online] 2019 [cited 2019 Dec 8];3:24-8. Available from: http://www.sccj-sa.org/text.asp?2019/3/1/24/259474




  Introduction Top


A pressure injury (PI) is a localized injury to the skin or the underlying tissue that results from unrelieved pressure. By compressing the small vessels, the pressure prevents the supply of oxygen and nutrients at the capillary level and the venous return of metabolic wastes. Moisture, shear, and friction may expedite tissue injury. PI usually occurs over bony prominences and may have different levels of severity depending on the depth of injury and involved tissues. [Table 1] describes the stages of PI according to the National Pressure Ulcer Advisory Panel (NPUAP).[1] Critically ill patients are at increased risk for acquiring PIs compared with other hospitalized patients because of the critical illness itself, the preexisting comorbid conditions, and the interventions performed in the intensive care unit (ICU). Significant PI risk factors in the ICU include low cardiac output state, vasopressor use, impaired level of consciousness, immobility, and decreased nutrition. Devices such as cervical collars, interfaces for noninvasive ventilation, sequential compression devices, surgical drains, enteral feeding tubes, and endotracheal intubation tubes are commonly used in the care of ICU patients and may also contribute to PI.[2] A systematic review of observational studies in the ICU setting found that the 95% confidence interval for the cumulative incidence of PI was 10.0%–25.9%.[3] The 95% confidence interval for the frequency of PI by location was as follows: sacrum 26.9%–48.0%, buttocks 4.1%–46.4%, heel 18.5%–38.9%, hips 10.9%–15.7%, ears 4.3%–19.7%, and shoulders 0.0%–40.2%.[3] Two studies from tertiary care centers in Saudi Arabia showed high PI incidence in both the ward and ICU setting, reaching approximately 40%.[4],[5] One of these studies reported that 20.1% of the PIs acquired in the ICU were device related.[5]
Table 1: Stages of pressure injury according to the National Pressure Ulcer Advisory Panel[1]

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PI is associated with increased morbidity, mortality, and health-care cost.[6],[7],[8],[9] A systematic review found that the cost of PI treatment varied from 1.7 to 470.5 €/patient/day across different settings.[9] PI is also considered a preventable adverse event of hospitalization including care in the ICU and has been recognized as a quality of care metric by many organizations including the Joint Commission International. Hence, PI prevention programs have gained significant focus by health-care institutions.


  Prevention of Pressure Injuries Top


PI prevention is dependent on two main cornerstones: PI risk assessment and application of various prevention measures in patients at risk.

Risk assessment for pressure injury

PI risk assessment requires adequate knowledge of PI mechanisms and stages. Unfortunately, health-care providers in general have suboptimal knowledge about PI definitions and care.[10],[11],[12] Hence, educating health-care providers about PI is important.

Routine risk assessment should be performed for all patients admitted to the ICU aiming at the early identification of those at risk. This will facilitate the planning and initiation of individualized preventive interventions. Risk assessment and skin inspection should be performed within 8 h of admission and at least daily thereafter.[1]

There are multiple tools for PI risk assessment. These tools include the Braden scale, Cubbin and Jackson scale, Norton scale, and Waterlow scale.[13] The Cubbin and Jackson scale is more specific to the ICU setting, but has not been shown to be superior to the other tools. The Braden Scale is one of the most commonly used tools. It is a summated rating scale that is made up of six subscales for a total score that ranges from 6 to 23.[14] A lower Braden Scale score indicates a higher risk for PI development. ICU patients are usually categorized into four PI risk groups depending on the Braden score as follows: low risk, >18; at risk, 15–18; moderate risk, 13–14; high risk, 10–12; and very high risk ≤9.[14] Based on a recent systematic review, there is uncertainty whether risk assessment makes any difference to PI incidence.[15]

The condition of the patient's skin is probably the most important indicator of how the skin will react to pressure exposure and the continuing risk of PI. Hence, ICU health-care providers should regularly perform a general visual inspection of the skin and check the skin beneath dressings and devices if applicable. Particular attention should be paid to areas of bony prominence, including the sacrum, heels, elbows, occiput, ears, shoulders, and knees. Clinicians should use their experience, clinical judgment, and knowledge to prevent tissue damage and protect the skin in conjunction with the screening tools.

Prevention measures

Nutritional support

Patients with poor nutritional status have increased risk of PI. In general, nutritional support should target prevention or correction of nutritional deficits. Based on indirect evidence, the guidelines of the NPUAP, the European Pressure Ulcer Advisory Panel, and the Pan Pacific Pressure Injury Alliance recommend providing 30–35 kcal/kg body weight and adequate protein to achieve positive nitrogen balance for adult patients at PI risk.[1] However, it remains unclear whether nutritional supplementation reduces the risk of developing PI. A systematic review and meta-analysis of eight trials (6062 patients) that compared mixed nutritional supplements with standard hospital diet found no clear effect of nutritional supplementation on PI development (risk ratio 0.86; 95% confidence interval, 0.73–1.00; P = 0.05).[16] Whether nonprotein caloric restriction is associated with higher PI incidence remains unknown.

Positioning and repositioning

Patients in the ICU should be positioned in a way to redistribute pressure and repositioned regularly to minimize the shear and friction forces on the skin. Limiting the time spent in one position to no more than 2 h is advised.[1] However, the repositioning frequency should take into consideration the general medical condition, skin condition, and comfort.[1] Repositioning can be a difficult task and should be undertaken by trained personnel using proper techniques to avoid further patient injury.

Redistribution of pressure

Pressure-redistributing support surfaces, such as mattresses, overlays, and integrated bed systems, are frequently used in hospitals to prevent PI. They offer redistribution of pressure on which patients are placed. They are designed to alternate the patient's body area in contact with the support surface and to reduce interface pressure through increasing the body surface area. There are different varieties of pressure-redistributing support surfaces. Examples of support surfaces include the low-air-loss mattresses, which are composed of multiple inflatable air tubes that alternately inflate and deflate, and the pressure-redistributing mattresses, which are made of high-density, highly-resilient foams, gels, and/or air chambers which allow for greater pressure distribution. Some surfaces provide active or powered pressure redistribution and others deliver passive or nonpowered redistribution.

In 2015, the American College of Physicians recommended against using alternating-air mattresses or alternating-air overlays in patients with increased risk of developing PI.[13] However, a recent systematic review and network meta-analysis that powered active air surfaces (risk ratio, 0.42; 95% confidence interval, 0.29–63) and powered hybrid air surfaces (risk ratio, 0.22, 95% confidence interval, 0.07–0.66) probably reduced PI incidence compared with standard hospital surfaces.[17] The evidence was judged to be of moderate quality.[17] Support surfaces that provide enhanced pressure redistribution, shear reduction, and microclimate control should be used in patients with Stages 3 and 4 and unstageable PI.[1]

Mobility

Immobility is a major risk factor for the development of PI. Mobilization of ICU patients is probably important in the prevention of PI. A before-after study at a medical ICU found that employing a mobility team, which consists of skin care prevention/mobility nurses and a patient mobility assistant, was associated with a significant decrease in ICU-acquired PI (6.1% vs. 9.2%, P = 0.04).[18]

Preventive skin care

This care includes individualized continence management plan, by keeping the skin clean and dry and applying moisturizers on dry skin and barrier products/creams on skin exposed to excessive moisture.[1] Barrier creams, which are made up of different materials and exist in different brands, form a protective layer that keeps away excessive moisture from incontinence, sweat, or wound drainage and aids in maintaining skin integrity.

Application of skin protective dressings

Hydrocolloid dressings, which contain an adhesive compound in combination with a water-resistant outer layer and are normally used in wound care, are frequently used in combination with barrier creams to prevent additional moisture exposure. Application of silicone foam dressings to anatomical areas frequently subjected to pressure friction and/or shear (e.g., heels and sacrum) should be considered.[1] There is growing evidence about the effectiveness of these dressings compared with standard methods. A before-after study found that the use of silicone foam dressing placed at the sacrum twice a week while following a standard PI prevention protocol was associated with a decrease in PI incidence from 12.3% to 1.8%.[19] A randomized controlled trial compared applying a silicone dressing on the sacrum and heels in trauma and critically ill patients in the emergency department, which was maintained throughout the ICU stay in 219 patients, with not doing so in 221 patients, and found significantly fewer patients with PIs in the intervention group compared with the control group (5 [3.1%] vs. 20 [13.1%], P = 0.001).[20] During the use of prophylactic dressings, routine skin inspection and all other preventive measures should be continued.

Multifaceted pressure injury prevention strategies

Preventing PIs in critically ill patients requires a structured, tailored, and multifaceted PI prevention approach with unit-based quality assurance projects that monitor PI prevalence and assess the effectiveness of the implemented preventive measures. Using the recently updated evidence-based guidelines on PI prevention and care is helpful.[1],[13]

Published studies on PI prevention emphasize the need for a multifaceted care approach and multidisciplinary involvement. In a before-after study, implementing PI prevention guidelines was associated with a decrease in the incidence of PI Stages 2–4 from a baseline of 54 to 32/1000 patient-days 12 months after guideline implementation (P = 0.001).[21] A recent study which evaluated a program that included the use of Braden scores to assess PI risk, a skin care protocol, fluidized re-positioners, and silicone gel adhesive dressings with staff education and motivation to prevent PIs found that the incidence of ICU-acquired PIs decreased by 69%, despite a 22% increase in patient load.[22] A pre-post study conducted in one medical-surgical ICU in Saudi Arabia found that, in patients with Braden scale score <18, the PRESSURE care bundle (positioning, risk assessment, elevation of heels, skin assessment, skin care and protective barriers, ultimate nutrition, relief of pressure, and elevation of head of bed) was associated with a significant reduction in the incidence of newly developed sacral PI in the 2-month treatment period (0.3%) compared with standard care (4.6%, P < 0.001).[23] The use of silicone foam dressing, especially at the sacrum and heels, in addition to standard preventive measures, may have additional benefit.[19],[20],[24],[25] A systematic review of 26 studies with moderate strength of evidence suggested that the integration of several core components improved processes of care and reduced PI rates.[26] The key components included the simplification and standardization of PI-specific interventions and documentation, involvement of multidisciplinary teams and leadership, use of designated skin champions, ongoing staff education, and sustained audit and feedback.[26] For device-related PIs, using the device according to the manufacturer's guideline is important.[27] Frequent inspection of skin at least twice daily for the signs of pressure-related injury on the surrounding tissue and placement of a rolled towel or foam dressings under the devices are also crucial for PI prevention.[1],[27]


  Conclusions Top


PI prevention has become a priority for ICUs as PI is associated with increased morbidity, its treatment is expensive, and critically ill patients are at higher risk for PI than other hospitalized patients. PI prevention relies on routine risk assessment and implementation of specific preventive measures, such as proper positioning and repositioning, proper skin care to avoid both dryness and excessive moisture, use of appropriate pressure-redistributing surfaces, and application of skin protective dressings. A multifaceted strategy, implemented as a protocol or algorithm, together with a quality assurance program, to identify the more effective interventions for a specific unit, is necessary to be successful. High-quality studies on PI prevention are lacking and are needed to improve clinical practices on PI prevention in hospitalized patients in general and ICU patients in particular.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. In: Haesler E, editor. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Osborne Park, Australia: Cambridge Media; 2014.  Back to cited text no. 1
    
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Makic MB. Medical device-related pressure ulcers and intensive care patients. J Perianesth Nurs 2015;30:336-7.  Back to cited text no. 2
    
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Chaboyer WP, Thalib L, Harbeck EL, Coyer FM, Blot S, Bull CF, et al. Incidence and prevalence of pressure injuries in adult intensive care patients: A systematic review and meta-analysis. Crit Care Med 2018;46:e1074-81.  Back to cited text no. 3
    
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Qaseem A, Mir TP, Starkey M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Risk assessment and prevention of pressure ulcers: A clinical practice guideline from the american college of physicians. Ann Intern Med 2015;162:359-69.  Back to cited text no. 13
    
14.
Smith LN, Booth N, Douglas D, Robertson WR, Walker A, Durie M, et al. Acritique of 'at risk' pressure sore assessment tools. J Clin Nurs 1995;4:153-9.  Back to cited text no. 14
    
15.
Moore ZE, Patton D. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database Syst Rev 2019;1:CD006471.  Back to cited text no. 15
    
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Langer G, Fink A. Nutritional interventions for preventing and treating pressure ulcers. Cochrane Database Syst Rev 2014;6:CD003216.  Back to cited text no. 16
    
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Shi C, Dumville JC, Cullum N. Support surfaces for pressure ulcer prevention: A network meta-analysis. PLoS One 2018;13:e0192707.  Back to cited text no. 17
    
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Azuh O, Gammon H, Burmeister C, Frega D, Nerenz D, DiGiovine B, et al. Benefits of early active mobility in the medical intensive care unit: A pilot study. Am J Med 2016;129:866-710.  Back to cited text no. 18
    
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Chaiken N. Reduction of sacral pressure ulcers in the intensive care unit using a silicone border foam dressing. J Wound Ostomy Continence Nurs 2012;39:143-5.  Back to cited text no. 19
    
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Santamaria N, Gerdtz M, Sage S, McCann J, Freeman A, Vassiliou T, et al. Arandomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: The border trial. Int Wound J 2015;12:302-8.  Back to cited text no. 20
    
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Swafford K, Culpepper R, Dunn C. Use of a comprehensive program to reduce the incidence of hospital-acquired pressure ulcers in an intensive care unit. Am J Crit Care 2016;25:152-5.  Back to cited text no. 22
    
23.
Amr AA, Yousef AM, Amirah MF, Alkurdi MH. A pre-post study evaluating the effectiveness of a new initiative, the “PRESSURE bundle,” Compared with standard care in reducing the incidence and prevalence of sacral pressure ulcers in critically Ill patients in an intensive care unit in Riyadh, Saudi Arabia. Saudi Crit Care J 2017;1:75.  Back to cited text no. 23
  [Full text]  
24.
Park KH. The effect of a silicone border foam dressing for prevention of pressure ulcers and incontinence-associated dermatitis in intensive care unit patients. J Wound Ostomy Continence Nurs 2014;41:424-9.  Back to cited text no. 24
    
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Byrne J, Nichols P, Sroczynski M, Stelmaski L, Stetzer M, Line C, et al. Prophylactic sacral dressing for pressure ulcer prevention in high-risk patients. Am J Crit Care 2016;25:228-34.  Back to cited text no. 25
    
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